www.smileinstyle.com.au - Child Dental Benefits

Smile in Style Child Dental Benefits

Please note that it is important to fill in all the fields before submitting. Thank you.
Patient Name *

First Name Middle Name Last Name
Child Dental Benefits Schedule Bulk Billing Patient Consent Form
I, certify that I have been informed:
- of the treatment that has been or will be provided from this date under the Child Dental Benefits Schedule; of the likely cost of this treatment; and that I will be bulk billed for services under the Child Dental Benefits Schedule and I will not pay out-of-pocket costs for these services, subject to sufficient funds being available under the benefit cap.
*

I understand that I / the patient will only have access to dental benefits of up to the benefit cap.
*

I understand that benefits for some services may have restrictions and that Child Dental Benefits Schedule covers a limited range of services. I understand I will need to personally meet the costs of any services not covered by the Child Dental Benefits Schedule.
*

I understand that the cost of services will reduce the available benefit cap and that I will need to personally meet the costs of any additional services once benefits are exhausted.
Patient’s Medicare Number
Patient’s Full Name *
Who signs? *

Patient Not the patient
form is valid up to 31 December of the calendar year for which it is signed
Your Signature *

Clear
Patient / legal guardian signature *

Clear
Name *

First Name Last Name
Full name of person signing *

First Name Last Name
Date *

Day Month Year
Date
Please verify that you are human *
Should be Empty:

Smile in Style Child Dental Benefits

Child Dental Benefits Schedule Bulk Billing Patient Consent Form